PLEASE CHOOSE THE AGENCY YOU WANT TO REGISTER WITH:

THIS APPLICATION FORM MUST BE COMPLETED USING

YOUR KEYBOARD AND MOUSE.

Please read this application form carefully before completing. Complete all sections of the application form to ensure you provide all of the information requested.

PLEASE COMPLETE ALL RELEVANT SECTIONS SHADED IN GREY

Select position applied for:

OR Enter Position:

Title:

Surname:

Middle Names:

First Name:

Telephone:

Mobile:

Mobile 2:

Email Address:

Address:

Post Code:

Date of Birth (dd/mm/yyyy):

Country of Birth: Nationality:

Are you eligible to work in the UK? Yes | No

NI Number:

NMC Pin No. (Registered Nurses only):

Pin Expiry (dd/mm/yyyy): dd/mm/yyyy

Do you have a full and Enhanced CRB from the last 12 months: Yes | No

If yes enter issue date (dd/mm/yyyy): and Reference No:

Do you hold a full UK Driver’s Licence: Yes | No

Your Next Of Kin:

Relationship to Next of Kin:

Address:

Post Code:

Telephone:

Mobile:

Mobile 2:

Email Address:

REFER YOUR COLLEAGUES AND EARN £50 FOR EACH ONE!
YOU PROVIDE US WITH THEIR DETAILS AND WE WILL DO THE REST!
NO / NAME / PHONE NUMBER / EMAIL / EARN
1. / £50
2. / £50
3. / £50
4. / £50
5. / £50

EXPERIENCE

EXPERIENCE / Less than
a year / 1
+Years / 2
+Years / 3
+Years / 4
+Years / 5
+Years / 10
+Years
Care of the Elderly
Community nursing
Mental health
Learning disabilities
Hospitals
Nursing homes
Paediatric
Occupational health
Prison service
Palliative care
Drug / alcohol rehabilitation
Additional Information:
Other (please specify)

EDUCATION

Education since 11 years old (any gaps must be explained)

PRIMARY SCHOOL EDUCATION

Name of School / City/Country / Dates (mm/yyyy) / Grades Obtained / Age on completion
From / To

SECONDARY EDUCATION

Name of School / City/Country / Dates (mm/yyyy) / Grades Obtained / Age on completion
From / To

COLLEGE & UNIVERSITY EDUCATION

Name of School / City/Country / Dates (mm/yyyy) / Grades Obtained / Age on completion
From / To

Professional Memberships Registrations

Organisation / Registration / Expiry Date
(mm/yyyy) / Renewal Date
(mm/yyyy)


MIDWIVES ONLY

Are you currently still practising? Yes | No

Intention to Practice form completed? Yes | No

Cardiotocography (CTG)Training give details:

Newborn Resuscitation Training give details:

Your Mentor/s Full Name:

(Take note your mentor must be one of your referees)


CLINICAL REFERENCES

Please give names and addresses of at least TWO referees, current employer and previous/most recent employer, who is in a position to comment on your work experience and suitability for the post to which you have applied. This must be a manager or supervisor.

If you have not been employed and/or never worked or you have not worked for some time, you could provide the name of a Head teacher or course tutor, supervisor etc. also any relevant work experience not less than two weeks.

Please do not give names of family members or friends. Note that the references you provide should have a direct relationship with your work and/or life history.

Reference One / Reference Two
Full Name: / Full Name:
Position: / Position:
Department: / Department:
Organisation: / Organisation:
Address:
Post Code: / Address:
Post Code:
Telephone:
Extension No: / Telephone:
Extension No:
Fax: / Fax:
Work Email: / Work Email:
Employment Date:
(mm/yyyy) / Employment Date:
(mm/yyyy)
From: / To: / From: / To:
Reference Three / Reference Four
Full Name: / Full Name:
Position: / Position:
Department: / Department:
Organisation: / Organisation:
Address:
Post Code: / Address:
Post Code:
Telephone:
Extension No: / Telephone:
Extension No:
Fax: / Fax:
Work Email: / Work Email:
Employment Date:
(mm/yyyy) / Employment Date:
(mm/yyyy)
From: / To: / From: / To:

Please note, references will be taken up prior to deployment for shifts and before commencing work. Our Agency expects that you had the work experience and qualifications that you have stated in your application.

CURRENT OR PREVIOUS EMPLOYER

(NOTE: if you were looking after children or self-employed, please state):

Name of Organisation:

Position Held:

Address:

Post Code:

Telephone: Fax:

Email Address:

Main duties and responsibilities:

From (mm/yyyy): To (mm/yyyy):

Reason for leaving:

Supervisor/Manager’s Full Name:

Hourly Rate (Per Hour £)

Additional supporting information:

PREVIOUS EMPLOYMENT IN DATE ORDER

(Please begin with the most recent first, including employment agencies)

NOTE: Any gaps in employment history must be explained.

Organisation Name
and Address / Dates (mm/yyyy) / Position / Main duties and responsibilities / Reason for leaving?
From / To

Have you ever been dismissed from employment, faced disciplinary action or awaiting hearing/investigation? Yes | No | If yes give details:

Please confirm if you agree for agency to contact your previous employers

Yes No
APPLICANT SKILL PROFILE

LEVEL OF COMPETENCE –Enter number in accordance with your level of expertise as indicated below:

1: I am familiar with this procedure and can perform independently.

2: I am familiar with this procedure but would need supervision.

3: Understand the theory behind the procedure, but have not performed it.

4: No contact with the equipment of this situation. No knowledge of procedure.

NUTRITION (PRESS F1 FOR HELP)

Preparation of meals

Feeding a helpless patient

GENERAL (PRESS F1 FOR HELP)

Pressure area care

Washing of personal laundry

Bedmaking: changing a bed or

drawersheet with patient in/on it

Light housework

Shopping

Care of terminally ill

*HEALTHCARE ASSISTANTS AND SUPPORT WORKERS ONLY*

Full Name:

Areas of specialty:

Grade:

PERSONAL HYGIENE (PRESS F1 FOR HELP)

Bath, shower, assisted wash

Use of bath aids

Mouth care (inc dentures)

Care of feet (exc. toenails)

Dressing/Undressing of patients

Bed bath

Shaving

Care of hair

Care of fingernails

Care of eyes

TOILETING (PRESS F1 FOR HELP)

Use of bedpans/commodes

Recording fluid balance

Emptying a catheter bag

Care of incontinent patient

EXPERIENCE

Hospital Yes | No

Nursing Home Yes | No

Hospice Yes | No

Patient with dementia Yes | No

First aid Yes | No

OTHERS

Maintaining client confidentiality

Yes | No

Report writing/giving

Yes | No

Observe changes in patient/clients condition and report to person in charge.

Yes | No

MOBILITY (PRESS F1 FOR HELP)

Lifting/Transferring patient

Use of walking aids

Use of hoists

Lifting/handling course

(evidence required)

OBSERVATION (PRESS F1 FOR HELP)

Temperature

Respiration

Blood pressure

Pulse

Urine testing

Other Skills/Comments:
Signature: / Date:


APPLICANT SKILL PROFILE

*QUALIFIED NURSES ONLY*

Full Name:

Areas of specialty:

Grade:

LEVEL OF COMPETENCE – Please select in accordance with your level of expertise as indicated below:

1: I am familiar with this procedure and can perform independently.

2: I am familiar with this procedure but would need supervision.

3: Understand the theory behind the procedure, but have not performed it.

4: No contact with the equipment of this situation. No knowledge of procedure.

ADMINISTRATION OF MEDICINES (PRESS F1 FOR HELP)

Oral administration

Injections

Administration of drugs in other forms e.g. eye, ear, nose drops etc

Administration of rectal and vaginal preparations

Topical application of drugs

Cytotoxic drugs

INTRAVENOUS THERAPY (PRESS F1 FOR HELP)

I.V. Rate calculations

Admission of drugs by continuous infusion

Admission of drugs by intermittent infusion

Admission of drugs by direct injection e.g. bolus or push

Heparinization of IV Cannula

Administration of blood and blood products e.g. plasma

Infusion pumps

Syringe drivers

Central venous catheter

Central venous pressure readings (CVP)

Venepuncture (taking blood)

Arterial lines:

Setting up for

Taking blood sample from

Removal of

TOTAL PARENTAL NUTRITION (PRESS F1 FOR HELP)

(TPA Hyperalimentation) knowledge of solutions

Assistance with insertion

Dressing change

GASTROINTESTINAL (PRESS F1 FOR HELP)

Naso-gastric tube insertion

Care of naso-gastric tube

Feeding via naso-gastric tube

Stoma care

Care of the patient with abdominal wounds/drains e.g.

gastrostomy, PEG tube, caecostomy drain

Care of patient undergoing abdominal paracentesis

Care of patient during and after liver biopsy

Administration of enemas

Administration of suppositories

Care of patient post abdominal surgery

Rectal lavage


APPLICANT SKILL PROFILE

*QUALIFIED NURSES ONLY* (Continued)

RENAL (PRESS F1 FOR HELP)

Insertion of catheter:

Male

Female

Catheter care

Suprapubic catheter

Nephrostomy tube

Bladder lavage and irrigation

Care of patient:

With renal transplant

On haemodialysis

With renal on peritoneal dialysis

Following nephfectomy

NEUROLOGICAL (PRESS F1 FOR HELP)

Neurological observations and assessment

Care of a patient during & following a seizure

Care of patient with a head injury:

Following a CVA

With a spinal cord injury (e.g. quadraplegic/paraplegic)

Following a spinal injury (e.g. laminectomy)

An unconscious patient

During or after a lumbar puncture

ORTHOPAEDICS (PRESS F1 FOR HELP)

Care of patient:

In plaster of Paris

With skin traction

With skeletal traction

Following amputation

Halo traction

Crutchrfield tongs

Stryker frame

Spinal lifts

Leg rolls

WOUND CARE (PRESS F1 FOR HELP)

Changing wound dressings

Aseptic technique

Removal of:

Sutures

Clips

Staples

Drain dressings

(e.g. keyhole – redivac and closed drainage system)

Change of vacuum bottle

Shortening of drain (e.g. penrose/corrugate)

Removal of pressure sores


APPLICANT SKILL PROFILE

*QUALIFIED NURSES ONLY* (Continued)

RESPIRATORY (PRESS F1 FOR HELP)

Oxygen therapy

Suctioning:

Oropharyngeal

Endotracheal

Tracheostomy care changing a dressing

Suctioning a trachestomy

Changing a trachestomy tube

Managing of chest tubes (under water seal drainage)

Changing drainage tubing and bottles (under water seal)

Removal of drainage tube

Care of ventilated patient

Obtaining arterial blood gases

Interpreting arterial blood gases

Assisting with intubation

CARDIOVASCULAR (PRESS F1 FOR HELP)

Perform 12 lead alectrocardiograms (ECG)

Cardiac monitoring

Telemetry

Cardiopulmonary resuscitation

Interpretation of basic arrhythmias

Defibrillation

Assisting with insertion of pacemaker

Aortic balloon pump

Swans-Ganz catheter

Care of patient with acute myocardial infraction

Care of patient with congestive cardiac failure

Care of patient post cardiac surgery

(e.g. coronary vein grafts, aortic valve replacement)

Care of patient post cardiac catheterisation

CARDIAC ARREST (PRESS F1 FOR HELP)

Knowledge of drugs used

Use of airway and ambu bag

Cardiac compressions

OTHERS (PRESS F1 FOR HELP)

Barrier nursing – infectious or immunosuppressed patient

Care of multiple trauma patients

Care of multiple with eye problems

Care of confused patient

Knowledge of the UKCC code of professional conduct

Knowledge of the UKCC guidelines for the administration of medicines


APPLICANT SKILL PROFILE

*QUALIFIED NURSES ONLY (Continued)*

Other Skills/Comments:
Signature: / Date:

HEALTH DECLARATION

**All members are required to complete this health declaration. Any positive answers will not necessarily effect your application**

General Practitioner or Occupational Health Department:
Tel No: / Address:
Postcode:

MEDICAL HISTORY

Have you ever been treated at the hospital for serious illness or surgery?

(If Please give dates)

Yes | No | Details:

How much time have you lost from work due to illness in the last five years?

(please provide details): none

Are you a registered disabled person?

Yes | No | Details:

What is the date of your last chest x-ray?

Yes | No | Details:

Have you ever suffered from any of the following?:

Heart/Circulatory illness/Hypertension

Yes | No | Details:

Diabetes

Yes | No | Details:

Asthma/Hayfever

Yes | No | Details:

Bronchitis/Pneumonia/Pleurisy

Yes | No | Details:


Tuberculosis

Yes | No | Details:

Epilepsy/ frequent fainting attacks

Yes | No | Details:

Psychiatric illness/Anxiety/Depression

Yes | No | Details:

Dermatitis, skin sensitivity (Allergies) Psoriasis/Eczema

Yes | No | Details:

Back injury/Back problems or Back Pains

Yes | No | Details:

Recurrent infections e.g. sore throats/ear infections

Yes | No | Details:

Hepatitis/Jaundice

Yes | No | Details:

Are you receiving medicines, pills or tablets from a doctor or on prescription?

Yes | No | Details:

Do you have any other physical disabilities other than those listed above that could affect your ability to carry out your assignment?

Yes | No | Details:

Have you ever been vaccinated, immunized or tested for/against any of the following?

Measles

Yes | No | Details:

Mumps

Yes | No | Details:

Varicella

Yes | No | Details:

Tuberculosis including BCG

Yes | No | Details:

Heaf, Mantoux or Tine

Yes | No | Details:

Rubella (German Measles)

Yes | No | Details:

Poliomyelitis

Yes | No | Details:

Hepatitis B

Yes | No | Details:

Hepatitis B antigen

Yes | No | Details:

Hepatitis B Antibodies Date & Result

Yes | No | Details:


Hepatitis C

Yes | No | Details:

HIV

Yes | No | Details:

Tetanus

Yes | No | Details:

Typhoid

Yes | No | Details:

Do you smoke: Yes | No

What is your Height: What is your current weight:

Signature: / Date:

DECLARATION

I understand that any offer of employment is subject to health clearance, Enhanced CRB disclosure and confirmation of statutory qualifications/registration if applicable.

I certify that the information given on this form is correct and understand that any misleading statements or deliberate omissions will be regarded as grounds for withdrawal of or subsequent disciplinary action, which could result in dismissal.

I understand that the information will be entered onto our computer database under the terms and conditions of the Data Protection Act 1998 and will be treated in a secure, confidential manner.

I have read and understood the OPT-OUT OF 48-HOUR WORKING WEEK AGREEMENT as described in the terms and conditions of engagement and I hereby consent that the working week limit shall not apply to my assignments in accordance with paragraph 3 of the agreement. I understand that under paragraph 4, WITHDRAWAL CONSENT, I can end this agreement by giving the Employment Business 14 day’s written notice.